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  • Domestic Visiting Student Medical Status Form: To Be Completed by Student

    Uploaded by

    Anonymous GKHVCwrm2f
    3 views1 page
    immunization form

    Original Title

    Immunization Form for sign

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    © © All Rights Reserved

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    immunization form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    3 views1 page

    Domestic Visiting Student Medical Status Form: To Be Completed by Student

    Uploaded by

    Anonymous GKHVCwrm2f
    immunization form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    DOMESTICVISITINGSTUDENTMEDICALSTATUSFORM

    Studentsname:_________________________________________________________

    Tobecompletedbystudent:
    Doyouhaveanyillnessthatmayinterferewithyourabilitytoworkonaclinicalservice?
    Yes[]No[]Ifyes,specify:
    ________________________________________________________________________________________________________
    ________________________________________________________________________________________________________
    Tobecompletedbythemedicalprovider:

    1. PhysicalExam:within12monthsofschoolsstart.Date:____________

    2. ScreeningforTuberculosis
    a)PPDwithin1yearoftheelectivesstartisrequired.

    PPDplantedDate:month/day/year________
    PPDreadDate:month/day/year________Results:_______mmInterpretation:Positive[]Negative[]

    b)ForstudentswithahistoryofpositivePPD:Chestxraywithin6monthsoftheelectivesstartisrequired.

    ChestxrayDate:month/day/year________Interpretation:________________________________
    Copyofthexrayresultmustbesubmitted.

    Iattestthatthestudentisfreeofsymptoms:hemoptysis,cough,fever,nightsweats,andweightloss.
    Initialsofmedicalprovider:_______

    3. Vaccines:

    Measles
    Mumps
    Rubella
    Varicella
    HepatitisB
    TdaP*
    MeaslesorMMR MumpsorMMR
    RubellaorMMR Dates:
    Dates:
    Date:
    Dates:
    Dates:
    Dates:
    Month/Year
    Month/Year
    Month/Year
    Month/Year
    Month/Year
    Month/Year
    1.
    1.
    1.
    1.
    1.
    1.
    2.
    2.
    2.
    2.
    2.
    3.

    IfVaccinerecordisnotavailable,checktitersandcompletebelow
    []Immune
    []Immune
    []Immune
    []Immune
    []Immune

    []Notimmune
    []Notimmune
    []Notimmune
    []Notimmune
    []Notimmune
    *IfTdonlywasgiven,thestudentneedsonedoseofTdaP.

    IncompliancewiththeNewYorkHealthCode,Iexaminedtheabovestudent.He/sheisfreefromanyhealthorbehavioralissues
    Iattestthattheaboveinformationistrue.

    MedicalProviderName:_____________________Signature:____________________Date:month/day/year____________

    Address/phone/email:____________________________________________________________________________________
    OfficeStamp:

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